Although research over the past two decades has described writing assignments in specific nursing programs (Gimenez, 2008, 2010; Lashley & Wittstadt, 1993; Rooda & Nardi, 1999; Zygmont & Schaefer, 2006), no studies have provided a complete picture of the extent to which nursing programs rely on English courses, general writing courses, or discipline-specific writing courses to help students become proficient academic writers in their disciplines. Whether academic writing genres should be taught within discipline-based courses or general composition courses (or perhaps not at all) remains a theoretical and practical issue (Bazerman et al., 2005; Brooks, 2002; Hansen & Adams, 2010) and is one of particular concern for those who determine curricula for professional programs. At the heart of the debate, as suggested by Bazerman et al. (2005), lie conflicting notions about the degree to which general composition courses may serve as a useful springboard into academic writing within specific disciplines. However, although general composition courses are a staple in U.S. universities, they remain the exception rather than the rule in Canada (Graves, 1994). Nonetheless, as Troxler, Jacobson Vann, and Oermann (2011) concluded, writing is a critical skill for nurses, and, as such, nursing programs have an obligation to ensure that nursing students are taught how to write well.
In this article, we review the English literature and writing course requirements in English-language nursing degree programs across Canada, and we discuss the relative merits of various approaches. We begin by briefly reviewing research on writing instruction in nursing education and consider three key developments that have combined to raise the profile of academic writing and research in the discipline of nursing.
Literature Review: What We Know About Writing In Nursing Education
Much of what we know about writing in nursing education derives from research in the United Kingdom and in the United States. In a study of academic writing experiences of nursing students in the United Kingdom, Whitehead (2002) found that students perceived a “lack of emphasis on…[and] support” (p. 504) for academic writing, and he identified a need for more writing instruction and support for nursing students. Gimenez (2008, 2010) also called for increased writing support based on his study of genres of writing assignments and the challenges these posed for nursing and midwifery students at a university in the United Kingdom.
Within the United States context, a recent literature review by Troxler et al. (2011) focused on writing programs in baccalaureate nursing programs. They found only nine programs reported in the literature, including three “stand-alone programs” (i.e., one writing workshop, one online writing tutorial, and one writing-intensive nursing course), as well as a few curriculum-wide approaches involving initiatives spanning several courses or, in one case, writing coaches (“ombudsmen”) (p. 281). Much of the literature on writing in nursing education in the United States has focused on writing-across-the-curriculum (WAC) initiatives. The WAC movement emphasizes the role of writing in learning and advocates the integration of writing tasks and instruction not only across disciplines but also across courses within disciplines (McLeod, 1992). Accounts of curricular changes in nursing programs guided by WAC principles include those of Lashley and Wittstadt (1993), who described how an analysis of the cognitive demands of written assignments led to changes in the design and sequencing of writing assignments in their program. Rooda and Nardi (1999) reported on a self-study that found an excessive number of writing assignments in their program (from 15 to 31 per semester) and an overemphasis on lower order thinking skills rather than the more critical skills required for reflective practice. Zygmont and Schaefer (2006) described a new portfolio requirement and the efforts to have instructors coordinate assignments and evaluation practices, emphasize critical thinking in writing assignments, and sequence assignments according to increasing cognitive challenges. Other researchers (Luthy, Peterson, Lassetter, & Callister, 2009; McCarthy & Bowers, 1994) focused on supports for WAC initiatives in nursing.
Within the Canadian context, relatively little has been published on students’ writing in nursing education. Graves (1993, 1994) found that of seven nursing faculties who responded to his 1990 survey of all undergraduate faculties in 61 Canadian universities, only four either required or encouraged their students to take a writing course. However, the respondents reported that their nursing programs rarely (if ever) offered writing instruction (defined in the study as designated courses or informal tutorials), although writing instruction was commonly offered within other professional schools (Graves, 1994). Thorpe and Kulig (1997) described a 1-day writing workshop implemented in their post-RN nursing program, as well as the draft writing exercises that were added to two nursing courses at the University of Lethbridge. Amirault, Doherty, LeBlanc, and Vickery (2005) described the introduction of a required writing workshop for baccalaureate nursing students at Dalhousie University. That workshop, developed in collaboration with nursing librarians, was recommended by a writing skills working group in the faculty of nursing. That group’s work also led to changes in assignment design and sequencing, as well as increasing the writing support for students through opportunities for review of drafted papers. Carter and Rukholm (2008) reported on a discipline-specific online writing course for RNs at Laurentian University and concluded that online courses work well to provide discipline-specific writing instruction.
Factors Contributing to an Increased Profile of Academic Writing In Nursing
Since Graves’ (1994) study, three developments in theory and practice have contributed to raising the profile and perceived importance of academic writing in nursing: (a) reconsideration of the importance of nursing scholarship, (b) a new institutionalized focus on evidence-based (or evidence-informed) practice as a competency for RNs, and (c) an increased emphasis on reflective practice and on the role of writing-to-learn within nursing programs.
As nursing has developed as a professional discipline, a university degree has become a standard requirement for new nurses entering the profession, and the role of nursing scholarship has been critically reexamined. This reexamination holds important implications for the integration of writing and research instruction in nursing programs. Drawing from the work of Boyer (1990), Scholarship Reconsidered: Priorities of the Professoriate, Riley, Beal, Levi, and McCausland (2002) proposed a revised model of nursing scholarship. Their work, along with Boyer’s, informed the position statement on scholarship in nursing developed by the Canadian Association of Schools of Nursing (2004, revised in 2006). Although the Canadian Association of Schools of Nursing’s position statement noted that “All nurses in academia [emphasis added] have a responsibility to engage in and advance scholarship” (p. 4), Riley et al. (2002) proposed a model based on the assumption that “all nurses, as members of a practice-based discipline, share in the obligation to take part in generating its scholarship” (p. 384). As Riley et al. (2002) explained, they envisioned “an emerging scholarly discipline whose members…contribute to the discipline from all nursing roles, regardless of work place” (p. 385). Zorn, Clark, and Weimholt (1997) called for an increased focus on scholarship in nursing education and linked it to the need for nurses’ participation in health care reform. In particular, they pointed to the need for nurses to develop higher order critical analysis skills, such as critique and synthesis, which are often developed through course writing assignments.
Although Riley et al. (2002) did not explicitly recommend the integration of writing and research instruction into nursing curricula, they advanced a view of nursing scholarship as central to both the academic discipline and the professional practice of nursing, bridging the theory–practice gap, while challenging traditional views in which scholarship remains the domain of experts in the field. Within this revitalized conception of nursing scholarship, writing courses take on increased importance because they provide opportunities for students to learn how to locate, interpret, and evaluate relevant sources on a question; summarize, synthesize, and critique research findings; and pursue lines of inquiry leading to their own research papers. In other words, when nursing scholarship is reconceived as part of the professional role for all nurses, nursing students must learn not only how to be competent nurses but also how to become competent writers and researchers capable of contributing to the scholarship in their field, a competence termed professional literacy by Smith and Caplin (2012). The influence of this new imperative is evident in Zorn et al.’s (1997) description of a professional writing course for nursing students—Educating the Nurse Scholar for the 21st Century: How an Interdisciplinary Writing Course Can Help. Also, Pullen, Reed, and Oslar’s (2001) account of assignment redesign, where a major care plan assignment was replaced with a major scholarly paper, was partially in response to nursing program accreditation bodies’ demands for “critical thinking and writing skills that demonstrate research-oriented development” (p. 81) in students.
Reconceptions of the role of nursing scholarship also underpin current understandings of evidence-informed practice as being central to competent nursing, which is a development that has important implications for the integration of research and writing instruction within nursing programs. As Tarrant, Dodgson, and Law (2007) noted, “Information literacy is the fundamental underpinning of evidence-based practice, and if nurses are not able to access and retrieve relevant up-to-date clinical information, their practice is not evidence-based” (p. 459). Traditionally, composition courses have included instruction on how to find, evaluate, effectively use, and properly document information from published sources that are relevant to a particular research question or writing task. Such instruction takes on greater significance in an environment in which graduate nurses are expected to possess not only specialized bodies of theory and knowledge and a set of technical skills but also the research skills to find “evidence to support the provision of safe, competent, ethical nursing care” (College and Association of Registered Nurses of Alberta, 2006, p. 9).
Although writing skills are not explicitly mentioned in the position statement or listed as an entry-to-practice competency by the Canadian Nurses Association (2010), it is clear that research assignments and writing papers in nursing programs are intended, at least in part, to help students to develop the research and critical thinking skills essential to an evidence-informed professional practice. By extension, writing courses in which students begin to develop research skills support nursing students on their journey to becoming competent nurses who are comfortable in an environment where evidence-informed practice is an expectation.
A final factor that has raised the profile of academic writing in nursing education is the increased emphasis on the role of writing in developing a reflective practice (Hannigan, 2001). In part as a legacy of the WAC movement, the increased focus on reflective writing and practice has shaped nursing curricula, assignment design, and modes of assessment in nursing courses (Craft, 2005; Dobie & Poirrier, 1996; Riley-Doucet & Wilson, 1997; Webster, 2002).
In the remainder of this article, we report on the English and writing course requirements for nursing students in Canada and discuss the relative merits of different approaches to writing instruction.
Nursing program and curriculum information for this study was gathered from publicly available Web sites of universities and colleges in Canada. We focused on 4-year baccalaureate programs in nursing, including collaborative programs offered jointly by two or more institutions (typically a university program with 1 or 2 years of study offered at a collaborating college). We also included the 2-year nursing baccalaureate program at the University of Toronto, as students enter the program with 2 full years of university courses already completed. We did not look at baccalaureate nursing programs offered in French or at programs for RNs or licensed professional nurses holding a diploma and seeking to complete a nursing degree. We also did not consider English proficiency requirements for entrance into nursing degree programs.
Working from the list of nursing degree programs in Canada that were posted on the Web site of the Canadian Nurses Association (2011), we examined the program curricula and required courses for all 81 English-language nursing programs. We recorded the English literature and writing course requirements for each program. Where links were provided to course descriptions, we reviewed the descriptions for all courses that appeared to relate explicitly to writing, composition, communication, and research, and we briefly reviewed nursing course descriptions. In the case of collaborative programs, we reviewed the Web sites and course descriptions for both collaborating institutions. We did not routinely consult course outlines or syllabi, but we searched such materials that are publicly available online in some cases where the descriptions provided on program Web sites lacked detail about the nature of a required English course.
In classifying courses, we considered only required courses. For example, if students were required to take an unspecified English course (e.g., 3 credits in English), then an English (literature) course was counted as a requirement. English courses were not counted as requirements when they were treated only as options in a broader list of program electives (e.g., in a list of humanities options). When course titles or calendar descriptions explicitly mentioned or emphasized writing, we classified the courses as writing courses—even when the writing and writing instruction in a particular course were likely to relate mainly to writing about literature. When programs specified that students must take either an English literature course or a writing course, the requirement was counted as an English (literature) course rather than as a writing course, although we did note cases in which a writing course was recommended but not required. We also noted specialized English literature and writing courses that were targeted specifically for nursing students, even when such courses were not required but were recommended or available as options.
The initial program requirements were coded by one of the principal researchers (J.A.) for this study and were reviewed by the second principal researcher (R.G.). The program requirements were reviewed and recoded by a second coder in May 2012. The second coder was a PhD student who was supervised and trained by one of the principal researchers (R.G.) for this study. Any discrepancies in the two rounds of data coding were discussed and resolved between the principal researchers.
Because the data gathering relied only on information publicly available online and did not involve research with human subjects, no research ethics review was sought from the research review boards of the researchers’ respective universities.
According to the list provided on the Web site of the Canadian Nurses Association (2011), there are 81 English-language baccalaureate nursing programs in Canada, including several collaborative programs offered jointly by two institutions. A review of the program Web sites indicated that nearly half (48.1%) of these programs do not require either an English literature or writing course (Table 1).
Table 1: Required English and Writing Courses in 81 English-Language Baccalaureate Nursing Programs in Canada in 2011–2012
English Literature Course Requirements
In 15 (18.5%) of the nursing programs, nursing students are required to take an English (literature) course. Two of the 15 programs require students to take two such courses, although students at North Island College are recommended to choose Essay Writing and Critical Analysis (Eng115), and Composition and Indigenous Literature 1 (Eng125), and students with English as an additional language in Trinity Western University’s nursing program are allowed to substitute Intro to Writing (Engl101) for one of the English literature courses.
Two nursing programs have begun to require or recommend specialized courses in English literature that are targeted for nursing students. For example, at Humber College of Applied Arts and Technology, nursing students are required to take Academic Writing and Critical Reasoning: Approaches to Literature (ENGL104). However, because this course title and description emphasizes writing, it was counted in our study as a required writing course. We noted only one other English literature course especially tailored for students in the health sciences—Introduction to Language and Literature (ENGL108), at the University of Alberta. Although this is a recommended rather than required course, we discuss it here as one of only two examples of English literature courses targeted specifically toward nursing students. According to a course outline available online, ENGL108 “combines formal instruction in writing with a study of the essay and the short story [and aims to help students to develop] an understanding of how illness and healing has been represented in some English-language texts” (Zenari, 2011, p. 1). Other course objectives emphasize critical thinking, close reading, idea generation, an understanding of plagiarism, and students’ development of “confidence in overall writing skills, especially with respect to effective professional communication” (Zenari, 2011, p. 1). Unlike most English courses, which traditionally require Modern Language Association documentation style, in ENGL108, students are required to use American Psychological Association style, the standard style required in nursing programs.
Writing Course Requirements
Five (6.2%) nursing programs require students to take both a writing and an English literature course. Included in this number is Vancouver Island University, which provides a range of options for these writing and literature courses. Often offered by the English department and labeled as English courses, most of these courses are generic in the sense that they are not targeted for nursing students and are likely to include students from a range of disciplines. In programs where English and writing courses are required, nearly all are required in the first year.
Required courses in academic writing that are targeted specifically for nursing students remain relatively rare. Besides Humber College’s ENGL104 course, only four other nursing programs require a discipline-specific writing course: the nursing program at Red River College, which requires students to take Scholarly Writing & Documentation (NRSG1501); the University of Calgary nursing program, which in 2010 began to require students to take Academic Writing for Specialized Audiences (Intermediate, ACWR303); Western University’s nursing program, which required students entering in 2012 and beyond to take Writing for Professional Success in Nursing (WRITING1030f/g); and Fanshawe College (a collaborating partner of Western University), which required its nursing students to take Professional Writing for Nurses (WRIT7004) beginning in 2012. The University of Victoria also offers a discipline-specific writing course—Academic Writing for Nurses (NURS300)—but it is an elective rather than a required course.
The discipline-specific ACWR303 course at the University of Calgary is an online course for nursing students, as well as students in Community Rehabilitation and Disability Studies. The course description in the university’s calendar notes a focus on “the writing styles, genres, and modes of evidence and reasoning appropriate to academic writing in a specific discipline” and states that “emphasis will be placed on connections between reading, writing, [and] critical reasoning” (University of Calgary, 2011, p. 295). The ACWR303 course materials include a focus on writing in nursing, examples drawn from nursing students’ papers, and an information search tutorial (WISPR [Workshop on the Information Search Process for Research]) that is based on the work of Kuhlthau (1997) and tailored for the needs of nursing students (Rutherford, Hayden, & Pival, 2006).
Nearly 40% of English-language nursing schools in Canada require their students to take a writing course. An additional 18.5% of nursing programs require students to take an English literature course—a requirement that may be, in part, intended to improve writing skills. Although nearly two decades ago, Graves (1993, 1994) noted an increase in the number of professional schools requiring students to take writing courses and a correlative decline in the number of such schools requiring students to take an English course, English literature course requirements persist in a significant proportion of nursing programs in Canada today.
The persistence of English literature course requirements may be explained by two separate, although perhaps related, notions—first, the perceived moral and cultural value that derives from the study of literature, and second, the perception of the English department as the unit responsible for engendering strong writing skills in students, regardless of specified course topics. Graves (1994) noted that many faculty administrators who responded to his survey “clearly count[ed] introduction to literature courses as writing courses” (pp. 49–50). It is likely that nursing program administrators still tend to perceive English literature courses as environments where students are likely to receive some writing instruction. However, Graves (1994) reminded us that in English literature courses, “the emphasis is almost always on critical reading, with instruction in writing treated as a peripheral activity” (p. 50).
Although English courses help students to develop the close reading, interpretive, and analytical skills central to academic writing in the humanities, the typical lack of focus on secondary research (including requirements to locate, evaluate, and synthesize information from secondary sources), the heavy reliance on quoting (rather than paraphrasing) when using sources as evidence, and the use of Modern Language Association style rather than American Psychological Association style makes English courses a less than optimal preparation for the writing required of nursing students in their nursing courses. In short, English essays and nursing research papers are different genres; whereas English essays are “explicitly interpretive” (Hyland, 2008, p. 550), nursing research assignments, like those in the social sciences, tend to focus on analyzing and synthesizing information from multiple sources (Hyland, 2008)—a task that is rare in junior-level English literature courses. If one goal of an English literature course requirement is to prepare nursing students for the writing tasks they will encounter in their nursing courses, perhaps required courses in English literature should be complemented (or replaced) by required writing courses with a focus on the genres of the writing required in nursing courses. (For one study of the genres of writing in nursing courses, see Graves & Chaudoir, 2009.)
Specialized or discipline-specific writing courses for nursing students are starting to be developed. Although only six such courses were noted among the 81 English-language nursing programs in Canada—including one elective that is not a program requirement—such courses appear to reflect an emerging trend, with the University of Calgary’s ACWR303 course requirement dating back to only 2010 and Western University’s WRITING1030f/g course and Fanshawe College’s WRIT7004 implemented in 2012.
Before we consider more closely the relative merits of required English literature courses, generic writing courses, and specialized or discipline-specific writing courses within nursing programs, we should define what we mean when referring to discipline-specific writing courses. Carter and Rukholm (2008) defined discipline-specific writing as “writing that reflects the writing conventions of the discipline, refers to the relevant literature, and ultimately enables a writer to assume membership in a particular discourse community” (p. 134). From this perspective, a discipline-specific writing course should focus on the genres and writing conventions of the discipline in question, it should provide opportunities for students to work with the literature in the field, and it should help them to develop discursive knowledge and writing skills and strategies that will help them to participate fully in their disciplines. As Carter (2007) indicated, discipline-specific writing courses should help students to develop the dynamic procedural knowledge integral to “writing as a way of knowing in a discipline” (p. 387). As a starting point for developing such courses, Carter usefully advocated a focus on desired outcomes.
In Table 2, we mapped possible desired outcomes related to writing courses in nursing and rated the likeliness of achieving those outcomes through an English literature course, an English literature course targeted for nursing students, a generic composition or academic writing course, and a discipline-specific writing course. As suggested in Table 2, a specialized course in writing for nurses is more likely to offer opportunities for students to generate research questions and to conduct research on a topic that relates to nursing or health care. For example, in the University of Calgary 2010 winter term’s ACWR303 course, nursing students researched and wrote about a variety of nursing or health care–related topics, including the prevention of falls among the elderly, the perceptions of male nursing students, and the safety and efficacy of ayurvedic treatments for rheumatoid arthritis. A discipline-specific writing course also provides a fitting context for instruction in the American Psychological Association documentation style and in the use of information search tools relevant to nursing. The integration of a specialized version of the WISPR tutorial on the information search and research-writing process in the University of Calgary’s ACWR303 course provides one example (Rutherford et al., 2006).
Table 2: Likeliness of Desired Outcomes of English Literature and Writing Courses in Nursing Programs
Perhaps most important, a discipline-specific writing course can introduce nursing students to the range of genres and kinds of evidence, analysis, modes of argument, and discourse conventions of the target discipline (Hyland, 2008). In contrast, in a one-size-fits-all writing course, instructors may be forced to overgeneralize about the appropriate use of evidence, the use (or avoidance) of headings, and proper documentation style. In other words, in a discipline-specific writing course, the genres of writing—understood in terms of both the composing (research) process and as written products—are more likely to resemble the genres of writing that students will be called on to produce in their nursing courses. General writing courses, or writing-intensive courses in other fields, are less likely to offer the learning opportunities that are relevant to research writing in nursing. For example, Zygmont and Schaefer (2006) recounted that students entering their upper-division nursing program after 2 years of study, which included five writing-intensive courses, did not possess the writing skills nursing instructors expected.
Our view of the value of discipline-specific writing courses aligns with that of Gimenez (2008), who concluded that writing instruction for nursing students should become more discipline specific. Gimenez also questioned the value of teaching students “genres they may never be required to produce, such as the ‘general’ academic essay” (p. 162), which may not transfer to writing in their discipline (Russell, 2002). Accounts of specialized writing courses in psychology (Hansen & Adams, 2010) and social work (Schuldberg et al., 2007) also attest to the potential benefits of discipline-specific writing courses.
Although research methods courses in nursing also help students to develop skills in locating, evaluating, synthesizing, and effectively using information from relevant sources in their discipline, such courses are almost always offered at the senior level of study. We believe that providing instruction in basic research writing early in a nursing program can benefit students by providing practical knowledge that will be useful in writing nursing research papers, which are commonly required at the junior level in many nursing programs (Giminez, 2008; Graves & Chaudoir, 2009). Instruction in basic research skills within the framework of a discipline-specific writing course can serve as a stepping stone to more advanced considerations of different modes of research and can begin to lay the groundwork for an evidence-informed nursing practice.
Over the past few decades, increased emphasis on the role of scholarship in nursing, increased expectations for evidence-based practice in nursing, and increased attention to the role of writing in learning and developing a reflective professional practice have combined to raise the profile of academic writing within the nursing curriculum. Writing-across-the-curriculum initiatives in nursing education have encouraged instructors to examine writing assignments and requirements at a programmatic level and to implement curricular changes designed to coordinate writing assignments across courses, to sequence assignments according to cognitive load, to incorporate more reflective writing and writing-to-learn activities, and to provide increased writing support for students.
In our research on English-language nursing baccalaureate programs in Canada, we found that nearly 40% of programs require students to take a writing course. We note the emergence of discipline-specific writing courses for nursing students and conclude that such courses may offer a number of benefits that are not shared by English literature or general writing course requirements. Given these potential benefits, we argue that discipline-specific writing courses are a useful adjunct to WAC initiatives in nursing. In our view, discipline-specific writing courses will help nursing students to develop the research and writing skills needed to succeed academically in their programs and to embark on a career in which nursing scholarship by practicing nurses is increasingly valued and in which evidence-informed practice has become an expectation.
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